Published on

  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide


  1. 1. Electronic Image of the MonthRegression of Hepatocellular Carcinoma With Right Atrial Extension AfterSorafenib and Transarterial ChemoembolizationMADHU SUBRAMANIAN,* AMIT G. SINGAL,‡ and ADAM C. YOPP**Department of Surgery, Division of Surgical Oncology, and ‡Department of Medicine, Division of Gastroenterology, University of TexasSouthwestern Medical Center, Dallas, TexasA 57-year-old man with a past medical history of hepatitis B infection presented for evaluation of a liver mass foundon surveillance abdominal ultrasound. On history and physical arterial supply (Figure B, arrowhead) of the tumor (Figure B, long arrow) and the tumor thrombus (Figure B, short arrow). Post- procedure noncontrast computed tomography of the abdomenexamination, he was a healthy-looking man with no pertinent showed uptake of Lipiodol within the parenchymal tumorsigns or symptoms of abdominal pain, ascites, hepatic enceph- (Figure C, long arrow) and tumor thrombus extending from thealopathy, or lower-extremity swelling. Laboratory results in- inferior vena cava into the right atrium (Figure C, short arrow).cluded the following: alanine aminotransferase level, 60 U/L; Periprocedurally, the patient was started on sorafenib therapytotal bilirubin level, 1.2 mg/dL; serum albumin level, 4.5 g/dL; (400 mg orally twice a day) because of the concern for potentialprothrombin time, 11.1 s; and international normalized ratio, systemic spread. At 1 year after a single transarterial chemoem-1.1. His ␣-fetoprotein level was 5 ng/mL. Magnetic resonance bolization treatment, magnetic resonance imaging of the abdo-imaging of the abdomen with gadolinium contrast showed a men showed not only a decrease in size of the parenchymal7.3-cm hypervascular mass with washout consistent with hep-atocellular carcinoma occupying segments 7 and 8 of the rightlobe of the liver with tumor thrombus invasion (Figure A, Conflicts of interestarrow) into the right hepatic vein, inferior vena cava, and right The authors disclose the following: Yopp and Singal are on theatrium. speakers board for Bayer and Onyx pharmaceuticals. The remaining The patient underwent selective transarterial chemoemboliza- author discloses no conflicts.tion consisting of Lipiodol (Guerbet LLC, Bloomington, IN), cis- © 2012 by the AGA Instituteplatin (100 mg), doxorubicin (50 mg), and mitomycin (10 mg), 1542-3565/$36.00with particle embolization (300 –500 ␮m embospheres) of the http://dx.doi.org/10.1016/j.cgh.2012.06.031 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2012;10:e83– e84
  2. 2. e84 IMAGE OF THE MONTH CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 10, No. 10mass but also no evidence of hypervascularity either in the vival benefit. With the efficacy of sorafenib and transarterialparenchymal mass (Figure D, arrow) or the inferior vena cava/ chemoembolization in systemic and locoregional disease con-right atrial tumor thrombus (Figure E, arrow). The patient trol, a combined treatment approach offers potential new mo-remains asymptomatic at 1 year with no further evidence of dalities in treating patients with a dismal prognosis.3,4viable tumor, metastatic disease, propagation of tumor intopulmonary vasculature, or findings from chronic liver disease,and he remains on sorafenib. References Hepatocellular carcinoma, the fifth most common cancer 1. El-Serag HB, Mason AC. Rising incidence of hepatocellular carci- noma in the United States. N Engl J Med 1999;340:745–750.worldwide, is the fastest growing cause of cancer-related deaths 2. Marrero JA, Fontana RJ, Barrat A, et al. Prognosis of hepatocellularin the United States.1 Vascular invasion including malignant carcinoma: comparison of 7 staging systems in an American cohort.tumor thrombus in the portal vein or hepatic vein/inferior vena Hepatology 2005;41:707–716.cava occurs in 31% to 38% of patients at initial presentation.2 3. Llovet JM, Real MI, Montaña X, et al. Arterial embolisation or che-The prognosis for patients with vascular invasion is dismal, moembolisation versus symptomatic treatment in patients with un-with the median overall survival generally less than 7 months.2 resectable hepatocellular carcinoma: a randomised controlled trial.Traditionally seen as a harbinger for systemic spread, treatment Lancet 2002;359:1734 –1739.for vascular invasion of the hepatic venous/inferior vena cava 4. Llovet JM, Ricci S, Mazzaferro V, et al. Sorafenib in advanced hep-system has relied on systemic chemotherapy with limited sur- atocellular carcinoma. N Engl J Med 2008;359:378 –390.